(navigation image)
Home American Libraries | Canadian Libraries | Universal Library | Community Texts | Project Gutenberg | Children's Library | Biodiversity Heritage Library | Additional Collections
Search: Advanced Search
Anonymous User (login or join us)
Upload
See other formats

Full text of "Ancient Classic Texts before 400 B.C."

On Fractures 
By Hippocrates 



Translated by Francis Adams 



PART 1 

In reating fractures and dislocations, the physician must make the 

extension as straight as possible, for this is the most natural direction. 

But if it incline to either side, it should rather turn to that of 

pronation, for there is thus less harm than if it be toward supination. 

Those, then, who act in such cases without deliberation, for the most 

part do not fall into any great mistake, for the person who is to 

have his arm bound, presents it in the proper position from necessity, 

but physicians who fancy themselves learned in these matters, are 

they who commit blunders. There is no necessity for much study, then, 

in order to set a broken arm, and in a word, any ordinary physician 

can perform it; but I am under the necessity of giving the longer 

directions on this subject, because I know physicians who have the 

reputation of being skilled in giving the proper positions to the 

arm in binding it up, while in reality they are only showing their 

own ignorance. But many other things in our art are judged of in this 

manner, for people rather admire what is new, although they do not 

know whether it be proper or not, than what they are accustomed to, 

and know already to be proper; and what is strange, they prefer to 

what is obvious. I must now state what the mistakes of medical men 

are, which I wish to unteach, and what instructions I have to give 

as to the management of the arm; for what I have to say regarding 

it, will apply to the other bones in the body. 



PART 2 

The arm, then, for that is the subject we were treating of, was presented 

in the prone position to be bound, but the physician forced his patient 

to hold it as the archers do when they project the shoulder, and in 

this position he bound it up, thinking within himself that he was 

acting according to Nature, and in proof of this he pointed out that 

all the bones in the fore-arm were thus in a straight line, and that 

the integuments both inside and outside, were also in a straight line, 

and that the flesh and nerves (tendons?) were thus put in their natural 

position, and he appealed to what happens in archery, as a proof of 

this. And so saying, and so doing, he is looked up to as a sage; and 

yet he forgets that in all the other arts and performances, whether 

executed whether executed by strength or dexterity, what is reckoned 

the natural position is not the same, and that in the same piece of 

work it may happen that the natural position of the right arm is not 

the same as that of the left. For there is one attitude in throwing 

the javelin, and another in slinging, another in casting stones, another 

in boxing, and another in a state of repose. And whatever arts one 

examines, it will be found that the natural position of the arms is 

not the same in each, but that in every case the arms are put into 

the attitude which suits best with the instrument that is used, and 

the work to be performed. In practicing archery, no doubt this is 

the best attitude of the left arm, for gingly-moid extremity of the 

humerus being fixed in the cavity of the ulna, in this position, throws 

the bones of the forearm and arm into a line, as if they constituted 

a single bone, and all flexion at the joint is prevented in this position. 

It is no doubt certain that the member is thus put into the most unbending 

and extended position possible, so as not to be overcome or yield 



when the string is drawn by the right arm, and thus will the archer 
be enabled to draw the string farthest, and discharge his arrow with 
the greatest force and rapidity, for arrows thus discharged have the 
greatest swiftness and force, and are carried to the greatest distances. 
But there is nothing in common between the binding up of an arm and 
archery. Moreover, if having thus bound up the arm, the physician 
direct the patient to keep it thus, he will occasion him greater pain 
than he had from the wound itself; and thus also, if the physician 
order him to bend the arm, neither the bones, the nerves, nor the 
flesh will any longer be in the same condition, but will be arranged 
differently, having overcome the bandaging. What use, then, is there 
of the archer's attitude? And these mistakes, the physician, conceited 
in his knowledge, would probably not have committed if he had allowed 
the patient himself to present his arm. 



PART 3 

But another physician putting the arm into the state of supination, 

gives orders to extend the arm thus, and bandages it in this position, 

reckoning it the one according to nature, judging thus from the skin, 

and also fancying the bones to be thus in their natural position, 

because the bone which protrudes at the wrist, where the little finger 

is, appears to be in a line with the bone from which people measure 

the bone of the fore-arm. These things he brings forward as proofs 

that the parts are in their natural state, and he is supposed to speak 

correctly. But, indeed, if the arm be kept stretched in a supine position, 

it will become very painful, and this fact any one may ascertain by 

extending his own arm in this attitude. And also a weaker man grasping 

with his hands a stronger man whose arm is turned in a supine position, 

could lead him wherever he chose, and neither, if a man held a sword 

thus in his hand, could he make any proper use of it, so constrained 

is this position. And, moreover, if, when a physician has thus bound 

up the arm, he allow it to remain in the same position, the patient 

will endure greater pain if he walk about, but considerable, even 

if he remain at rest. And thus, too, if he shall bend the arm, the 

muscles and the bones must necessarily assume a different position. 

But, in addition to other mischief, he is ignorant of these facts 

regarding the position, that the bone which protrudes at the wrist, 

close to the little finger, belongs to the fore-arm, whereas the one 

at the joint, from which people measure the fore-arm, is the head 

of the humerus. He fancies that both these belong to the same bone, 

and many others are of this opinion. The latter, in fact, is the same 

part as that which is called the elbow, upon which we sometimes rest, 

and when he holds the arm thus in a supine position, in the first 

place the bone appears distorted, and in the next place the tendons 

which extend from the carpus along the inner side and from the fingers 

become distorted while the arm has a supine position; for these tendons 

proceed to the bone of the humerus, from which the fore-arm is measured. 

Such, and so many mistakes and marks of ignorance are committed, regarding 

the natural construction of the arm. But if one will extend a broken 

arm as I direct, he will turn the bone, situated at the extremity 

of the little finger, into the straight line, and also the one at 

the elbow, and the tendons which stretch from the carpus to the extremity 

of the humerus will be placed in the straight line; and when the arm 

is suspended in a sling, it will be in the same attitude as that in 

which it was bound up, and will give no pain to the patient when he 

walks about, nor when he lies reclined, and will not become fatigued. 

The man should be so seated that the prominent part of the bone may 

be turned to the brightest light which is at hand, so that the operator 

in making the extension, may be at no loss to discover if it be sufficiently 

straight. The prominence of a broken bone could not escape being detected 

by the hand of an experienced person, when applied for this purpose. 



and, moreover, the projecting part is particularly painful to the 
touch . 



PART 4 

In cases of fracture in either of the bones of the forearm, it is 

easier to effect a cure if the upper bone be broken, although it be 

the thicker one, both because the sound bone is situated below, and 

forms a support to it, and because the deformity is more easily concealed, 

there being a thick mass of flesh on the upper side, except near to 

the wrist. But the lower bone is without a covering of flesh, is not 

easily concealed, and requires stronger extension. If it is not this 

bone, but the other which is broken, a more feeble extension proves 

sufficient, but if both be broken, a more powerful extension is required. 

In the case of a young person I have known the extension made more 

strong than was necessary, but in general the extension made is less 

than what is required. And when they are extended, the physician should 

apply the palms of the hands, and adjust the fractured parts and then 

having rubbed the parts with cerate, but not in large quantity so 

that the bandages may not come off, it is to be bound up in this state, 

care being taken that the hand be not lower than the elbow, but a 

little higher, so that the blood do not flow toward the extremity, 

but may be determined to the upper part; and then it is to be secured 

with the bandage, the head of which is to be placed at the fracture, 

and the bandage should impart firmness to the parts without occasioning 

strong compression. When you have carried the bandage twice or thrice 

round at the seat of the fracture, it is to be carried upward, so 

that the afflux of blood into it may be stopped, and the bandage should 

terminate there, and the first bandages ought not to be long. The 

head of the second bandage is also to be placed upon the seat of the 

fracture, and a single round of it being made there, it is then to 

be carried downward, and is not to be applied so tight as the other, 

and there should be greater distances between the turns, so that the 

bandage may prove sufficient to revert to the spot where the other 

terminated. The bandages may be rolled to the left hand or to the 

right, or to whatever side suits best with the position of the fractured 

arm, or according to the inclination which it may have. Afterward 

we must place along the arm, compresses, smeared with a little cerate, 

for thus they occasion less uneasiness, and are more easily arranged. 

And then we must apply the bandages crossways, sometimes to the right 

hand, and sometimes to the left, for the most part beginning below 

and terminating above, but sometimes commencing above and ending below. 

The parts which are thinly covered with flesh should be wrapped round 

with compresses, and inequalities should be made up, not by a number 

of folds at once, but by degrees. Some slack turns are also to be 

made around the wrist, to this side and to that. These two bandages 

are sufficient at first. 



PART 5 

And these are the signs that the patient has been well treated and 
properly bandaged: if you ask him if the arm feels tight, and he says 
it does, but moderately so, and especially about the fracture; and 
this reply he should make all along, if the bandage be properly applied. 
And these are symptoms of the bandaging being moderately tight; if 
for the first day and night he fancies that the tightness does not 
diminish, but rather increases; and if on the next day there be a 
soft swelling in the hand, for this is a sign of moderate compression, 
but at the end of the second day the compression should feel less, 
and on the third day the bandaging should appear loose. And if any 



of these symptoms be wanting, you may conclude that the bandaging 
is slacker than it should be; or if any of these symptoms be in excess, 
you may infer that the compression is more than moderate; and judging 
from these, you will apply the next bandages either slacker or tighter. 
Having removed the bandages on the third day, you must make extension 
and adjust the fracture, and bind it up again; and if the first bandaging 
was moderately applied, the second bandaging should be made somewhat 
tighter. The heads the bandages should be placed on the fractures 
as in the former case; for, so doing, the humors will be driven to 
the extremities, whereas if you bandage any other part beforehand, 
the humors will he forced from it to the seat of the fracture: it 
is of much importance that this should be properly understood. Thus 
the bandaging and compression should always commence at the seat of 
the fracture, and everything else should be conducted on the same 
principle, so that the farther you proceed from the fracture, the 
compression should always be the less. The bandages should never be 
actually loose, but should be smoothly put on. At each dressing the 
number of bandages should be increased; and the patient, if asked, 
should answer, that he feels the bandages somewhat tighter than on 
the former occasion, especially about the fracture, and everything 
else in proportion; and with respect to the swelling, the pain, and 
recovery, everything should proceed as after the former dressing. 
But on the third day the outer bandaging should appear looser. Then 
having removed the bandages, you should bind it up again, somewhat 
tighter than before, and with all the bandages which will be required 
on the occasion, and afterwards one ought to experience the same train 
of symptoms as at the former periods of bandaging. 



PART 6 

When the third day arrives, that is to say, the seventh from the first 
dressing, if properly done, the swelling in the hand should be not 
very great; and the part which has been bandaged should be found more 
slender and less swelled at each time, and on the seventh day the 
swelling should be quite gone, and the broken bones should be more 
readily moved, and admit of being easily adjusted. And if these things 
be so, you should, after setting the fracture, apply the bandages 
so as to suit the splints, and a little more tight than formerly, 
unless there be more pain from the swelling in the hand. When you 
have applied the bandages, you must adjust the splints all around 
the limb, and secure them secure them with strings so loose as just 
to keep them in their place, without the application of the splints 
contributing at all to the compression of the arm. After this the 
pain and recovery should proceed as in the preceding periods of the 
bandaging. But if, on the third day, the patient say that the bandaging 
is loose, you must then fasten the splints, especially at the fracture, 
but also elsewhere, wherever the bandaging is rather loose than tight. 
The splint should be thickest where the fracture protrudes, but it 
should not be much more so than elsewhere. Particular attention should 
be paid to the line of the arm corresponding to the thumb, so that 
no splint be laid on it, but upon each side of it, nor in the line 
of the little finger where the bone is prominent at the wrist, but 
on each side of it. And if it be found necessary that splints should 
be applied in these directions at the seat of the fracture, they should 
be made shorter than the others, so as that they may not reach the 
bones which are prominent at the wrist, for otherwise there is danger 
of ulceration, and of the tendons being laid bare. The splints should 
be adjusted anew every third day, in a very gentle manner, always 
keeping in mind that the object of the splints is to maintain the 
lower bandages in their place, and that they are not needed in order 
to contribute to the compression. 



PART 7 

If, then, you see that the bones are properly adjusted by the first 

dressings, and that there is no troublesome pruritus in the part, 

nor any reason to suspect ulceration, you may allow the arm to remain 

bandaged in the splints until after the lapse of more than twenty 

days. The bones of the fore-arm generally get consolidated in thirty 

days altogether; but there is nothing precise in this matter, for 

one constitution differs from another, and one period of life from 

another. When you remove the bandages, you must pour hot water on 

the arm and bind it up again, but somewhat slacker, and with fewer 

bandages than formerly: and again on the third day you undo the bandages, 

and bind it still more loosely, and with still fewer bandages. And 

if, while the arm is bound up in the splints, you should at any time 

suspect that the bones do not lie properly, or if anything about the 

bandages annoys the patient, you should loose them at the middle of 

the time, or a little earlier, and apply them again. A diet slightly 

restricted will be sufficient in those cases in which there was no 

external wound at first, or when the bone does not protrude; but one 

should live rather sparingly until the tenth day, as being now deprived 

of exercise; and tender articles of food should be used, such as moderately 

loosen the bowels; but one should abstain altogether from flesh and 

wine, and then by degrees resume a more nourishing diet. This diet. 

may be laid down as a just rule in the treatment of fractures, both 

as to how they should be treated, and what will be the results of 

a proper plan of treatment; so that one may know, that if things do 

not turn out thus, there has been some defect or excess in the treatment. 

And in this simple plan of treatment it is necessary to attend also 

to the following directions, which some physicians pay little attention 

to, although, when improperly executed, they are capable of marring 

the whole process of bandaging: for if both the bones be broken, or 

the lower one only, and the patient who has got his arm bandaged keep 

it slung in a shawl, and that the shawl is particularly loose at the 

fracture, so that the arm is not properly suspended at this end or 

that, in this case the bone must necessarily be found distorted upwards; 

whereas, when both bones are thus broken, if the arm recline in the 

shawl at the wrist and elbow, but the rest of it be not kept up, the 

bone in this case will be distorted to the lower side. The greater 

part of the arm and the wrist of the hand should therefore be equally 

suspended in a broad soft shawl. 



PART 8 

When the arm is broken, if one stretch the fore-arm and adjust it 
while in this position, the muscle of the arm will be bound while 
extended; but when the dressing is over, and the patient bends his 
arm at the elbow, the muscle of the arm will assume a different shape. 
The following, then, is the most natural plan of setting the arm: 
having got a piece of wood a cubit or somewhat less in length, like 
the handles of spades, suspend it by means of a chain fastened to 
its extremities at both ends; and having seated the man on some high 
object, the arm is to be brought over, so that the armpit may rest 
on the piece of wood, and the man can scarcely touch the seat, being 
almost suspended; then having brought another seat, and placed one 
or more leather pillows under the arm, so as to keep it a moderate 
height while it is bent at a right angle, the best plan is to put 
round the arm a broad and soft skin, or broad shawl, and to hang some 
great weight to it, so as to produce moderate extension; or otherwise, 
while the arm is in the position I have described, a strong man is 
to take hold of it at the elbow and pull it downward. But the physician 



standing erect, must perform the proper manipulation, having the one 
foot on some pretty high object, and adjusting the bone with the palms 
of his hands; and it will readily be adjusted, for the extension is 
good if properly applied. Then let him bind the arm, commencing at 
the fracture, and do otherwise as directed above; let him put the 
same questions and avail himself of the same signs to ascertain whether 
the arm be moderately tight or not; and every third day let him bind 
it anew and make it tighter; and on the seventh or ninth day let him 
bind it up with splints, and leave it so until after the lapse of 
more than thirty days. And if he suspect that the bone is not lying 
properly, let him remove the bandages in the interval, and having 
adjusted the arm, let him bind it up again. The bone of the arm is 
generally consolidated in forty days. When these are past, the dressing 
is to be removed, and fewer and slacker bandages applied instead of 
it. The patient is to be kept on a stricter diet, and for a longer 
space of time than in the former case; and we must form our judgment 
of it from the swelling in the hand, looking also to the strength 
of the patient. This also should be known, that the arm is naturally 
inclined outward; to this side, therefore, the distortion usually 
takes place, if not properly treated; but indeed, all the other bones 
are usually distorted during treatment for fracture to that side to 
which they naturally incline. When, therefore, anything of this kind 
is suspected, the arm is to be encircled in a broad shawl, which is 
to be carried round the breast, and when the patient goes to rest, 
a compress of many folds, or some such thing, is to be folded and 
placed between the elbow and the side, for thus the bending of the 
bone will be rectified, but care must be taken lest it be inclined 
too much inwards . 



PART 9 

The human foot is composed of several small bones like the hand. These 
bones therefore are scarcely ever broken, unless the skin at the same 
time be wounded by some sharp and heavy body. The treatment of stich 
injuries, therefore, will be delivered under the head of wounds. But 
if any bone be moved from its place, or a joint of the toes be luxated, 
or any of the bones of the part called the tarsus be displaced, it 
must be forced back again to its place as described with regard to 
the hand; and is to be treated with cerate, compresses, and bandages, 
like the fractures, with the exception of the splints; and is to be 
secured tightly in the same way, and the bandages renewed on the third 
day; and the patient thus bandaged should return the same answers 
as in fractures, as to the bandages feeling tight or slack. All these 
bones recover perfectly in twenty days, except those that are connected 
with the bones of the leg, and are in a line with them. It is advantageous 
to lie in bed during the whole of this time; but the patients, thinking 
light of the complaint, have not perseverance to do this, and they 
walk about before they get well; wherefore many of these do not make 
a perfect recovery. And often the pain puts them in mind of the injury; 
and deservedly, for the feet sustain the weight of the whole body. 
When, therefore, they walk about before they are whole, the joints 
which have been luxated are cured incompletely; and, on that account, 
while walking about, they have pains in the leg from time to time. 



PART 10 

But those bones which are connected with the bones of the leg are 
larger than the others, and the cure of them when luxuated is more 
protracted. The mode of treatment then is the same; but we must use 
more bandages and more splints, and the bandage is to be carried round 



to this side and to that, and pressure is to be made as in the other 
cases, particularly at the seat of the luxation, and the first circles 
of the bandages are to be made there. And at each time the bandages 
are taken off, much hot water is to be used, for in all injuries at 
joints the affusion of hot water in large quantity is to be had recourse 
to. And the same symptoms of compression and relaxation should manifest 
themselves in the same times, as in the cases formerly treated of, 
and the subsequent bandagings should be conducted in like manner. 
These cases get completely well for the most part in forty days, if 
the patients have resolution to keep their bed; but if not, they are 
subjected to the complaints formerly described, or still worse. 



PART 11 

In persons who jumping from any high object pitch upon their heel 
with great force, the bones are separated, and the veins pour forth 
their contents, owing to the contusion of the flesh surrounding the 
bone, and hence a swelling and much pain supervene. For this bone 
(os calcis) is not a small one, protrudes beyond the line of the leg, 
and is connected with important veins and tendons; for the back tendon 
of the leg is inserted into this bone. Such cases are to be treated 
with cerate, and with compresses and bandages; and hot water is to 
be used in large quantity; and they require many bandages, which ought 
to be particularly good and appropriate. And if the patient happen 
to have a tender skin about the heel, nothing is to be done to it; 
but if, as some have it, the skin be thick and hardened, it is to 
be pared down smoothly and thinned, but without wounding it. It is 
not everybody who can apply the bandage properly in such cases; for 
if one shall bind the parts, as in other accidents about the ankle, 
sometimes bringing a fold round the foot and sometimes round the tendon, 
these turns leave out the heel, which is the seat of the contusion, 
and thus there is danger that the os calcis may sphacelate; and if 
this should take place, the impediment may endure for life and also 
in all the other cases of sphacelus, not proceeding from such a cause 
as this; as when, from being carelessly allowed to lie in a certain 
position during confinement to bed, the heel becomes black, or when 
a serious wound has occurred in the leg and it is long of healing, 
and is connected with the heel, or when the same thing happens in 
the thigh, or when in any disease a protracted decubitus takes place 
on the back, in all such cases the sores are inveterate, troublesome, 
and frequently break out again, unless particular attention be paid 
to the cure, along with much rest, as in all the cases attended with 
sphacelus. And cases of sphacelus connected with this cause, in addition 
to other inconveniences, are attended with great danger to the whole 
body. For they are apt to be attended with very acute fevers, of the 
continual type, accompanied with tremblings, hiccup, aberration of 
intellect, and which prove fatal within a few days: and there may 
be lividities of bloody veins, with nausea, and gangrene from pressure; 
these diseases may occur, besides the sphacelus. Those which have 
been described are the most violent contusion; but in general the 
contusions are mild, and no great care is required with regard to 
the treatment, and yet it must be conducted properly. But when the 
contusion appears to be severe, we must do as described above, making 
many turns of the bandage around the heel, sometimes carrying it to 
the extremity of the foot, sometimes to the middle, and sometimes 
around the leg; and, in addition, all the surrounding parts are to 
be bandaged in this direction and that, as formerly described; and 
the compression should not be made strong, but we should make use 
of many bandages, and it is better also to administer hellebore the 
same day or on the morrow; and the bandages should be removed on the 
third day and reapplied. And these are the symptoms by which we discover 
whether the case will get worse or not: when the extravasated blood. 



the lividities, and the surrounding parts become red and hard, there 

is danger of an exacerbation. But if there be no fever, we must give 

emetics, as has been said, and administer the other remedies which 

are applicable when the fever is not of a continual type; but if continual 

fever be present, we must not give strong medicines, but enjoin abstinence 

from solid food and soups, and give water for drink, and not allow 

wine but oxyglyky (a composition from vinegar and honey?) . But if 

the case be not going to get worse, the ecchymosed and livid parts, 

and those surrounding them become greenish and not hard; for this 

is a satisfactory proof in all cases of ecchymosis, that they are 

not to get worse; but when lividity is complicated with hardness, 

there is danger that the part may become blackened. And we must so 

manage the foot as that it may be generally raised a little higher 

than the rest of the body. Such a patient will get well in sixty days 

if he keep quiet. 



PART 12 

The leg consists of two bones, of which the one is much more slender 
than the other at one part, but not much more slender at another. 
These are connected together at the foot, and form a common epiphysis, 
but they are not united together along the line of the leg; and at 
the thigh they are united together and form an epiphysis, and this 
epiphysis has a diaphysis; but the other bone in a line with the little 
toe is a little longer. Such is the nature of the bones of the leg. 



PART 13 

Sometimes the bones connected with the foot are displaced, sometimes 
both bones with their epiphysis; sometimes the whole epiphysis is 
slightly moved, and sometimes the other bone. These cases are less 
troublesome than the same accidents at the wrist, if the patients 
will have resolution to give them rest. The mode of treatment is the 
same as that of the other, for the reduction is to be made, as of 
the other, by means of extension, but greater force is required, as 
the parts of the body concerned are stronger in this case. But, for 
the most part, two men will be sufficient, by making extension in 
opposite directions, but, not withstanding, if they are not sufficiently 
strong, it is easy to make more powerful extension in the following 
way: having fixed in the ground either the nave of a wheel, or any 
such object, something soft is to be bound round the foot, and then 
some broad thongs of ox-skin being brought round it, the heads of 
the thongs are to be fastened to a pestle or any other piece of wood, 
the end of which is to be inserted into the nave, and it, the pestle, 
is to be pulled away, while other persons make counter-extension by 
grasping the shoulders and the ham. It is also sometimes necessary 
to secure the upper extremity otherwise; this if you desire to effect, 
fasten deeply in the ground a round, smooth piece of wood, and place 
the upper extremity of the piece of wood at the perineum, so that 
it may prevent the body from yielding to the pulling at the foot, 
and, moreover, to prevent the leg while stretched, from inclining 
downward; some person seated at his side should push back the hip, 
so that the body may not turn round with the pulling, and for this 
purpose, if you think fit, pieces of wood may be fastened about the 
armpits on each side, and they are to be stretched by the hands, and 
thus secured, while another person takes hold of the limb at the knee, 
and aids in thus making counter-extension. Or thus, if you prefer 
it: having bound other thongs of leather about the limb, either at 
the knee, or around the thigh, and having fastened another nave of 
a wheel in the ground above the head, and adjusted the thongs piece 



of wood adapted to the nave, extension may thus be made in the opposite 

direction to the feet. Or if you choose, it may be done thus: instead 

of the naves, lay a moderate-sized beam under the couch, and then 

having fastened pieces of wood in this beam, both before and behind 

the head, make counter-extension by means of thongs, or place windlasses 

at this extremity and that, and make extension by means of them. There 

are many other methods of making extension. But the best thing is, 

for any physician who practices in a large city, to have prepared 

a proper wooden machine, with all the mechanical powers applicable 

in cases of fractures and dislocation, either for making extension, 

or acting as a lever. For this purpose it will be sufficient to possess 

a board in length, breadth, and thickness, resembling the quadrangular 

threshing-boards made of oak. 



PART 14 

When you have made proper extension, it is easy reduce the joint, 

for the displaced bone is thus raised into a line with the other. 

And the bones are to be adjusted with the palms of the hands, pressing 

upon the projecting bone with the one, and making counter-pressure 

below the ankle with the other. When you have replaced the bones, 

you must apply the bandages while the parts are upon the stretch, 

if you possibly can; but if prevented by the thongs, you must loose 

them, and make counter-extension until you get the bandages applied. 

The bandage is to be applied in the manner formerly described, the 

heads of the bandages being placed on the projecting part, and the 

first turns made in like manner, and so also with regard to the number 

of compresses and the compression; and turns of the bandages are to 

be brought frequently round on this and on that side of the ankle. 

But this joint must be bound more tight at the first dressing than 

in the case of the hand. But when you have applied the bandage, you 

must place the bandaged part somewhat higher than the rest of the 

body, and in such a position that the foot may hang as little as possible. 

The attenuation of the body is to be made proportionate to the magnitude 

of the luxation, for one luxation is to be a small, and another to 

a great extent. But in general we must reduce more, and for a longer 

time, in injuries about the legs, than in those about the hands; for 

the former parts are larger and thicker than the latter, and it is 

necessary that the body should be kept in a state of rest, and in 

a recumbent position. There is nothing to prevent or require the limb 

to be bandaged anew on the third day. And all the treatment otherwise 

is to be conducted in like manner, as in the preceding cases. And 

if the patient have resolution to lie quiet, forty days will be sufficient 

for this purpose, if only the bones be properly reduced, but if he 

will not lie quiet, he will not be able to use the limb with ease, 

and he will find it necessary to wear a bandage for a long time. When 

the bones are not properly replaced, but there has been some defect 

in this respect, the hip, the thigh, and the leg become wasted, and 

if the dislocation be inward, the external part of the thigh is wasted, 

and vice versa. But for the most part the dislocation is inward. 



PART 15 

And when both bones of the leg are broken without a wound of the skin, 
stronger extension is required. We may make extension by some of the 
methods formerly described, provided the bones ride over one another 
to a considerable degree. But extension by men is also sufficient, 
and for the most part two strong men will suffice, by making extension 
and counterextension . Extension must naturally be made straight in 
a line with the leg and thigh, whether on account of a fracture of 



the bones of the leg or of the thigh. And in both cases they are to 

be bandaged while in a state of extension, for the same position does 

not suit with the leg and the arm. For when the fractured bones of 

the arm or fore-arm are bandaged, the fore-arm is suspended in a sling, 

and if you bind them up while extended, the figures of the fleshy 

parts will be changed in bending the arm at the elbow, for the elbow 

cannot be kept long extended, since persons are not in the custom 

of keeping the joint long in this form, but in a bent position, and 

persons who have been wounded in the arm, and are still able to walk 

about, require to have the arm bent at the elbow-joint. But the leg, 

both in walking and standing, is habitually extended, either completely 

or nearly so, and is usually in a depending position from its construction, 

and in order that it may bear the weight of the rest of the body. 

Wherefore it readily bears to be extended when necessary, and even 

when in bed the limb is often in this position. And when wounded, 

necessity subdues the understanding, since the patients become incapable 

of raising themselves up, so that they neither think of bending the 

limb nor of getting up erect, but remain lying in the same position. 

For these reasons, neither the same position nor the same mode of 

bandaging applies to the arm and to the leg. If, then, extension by 

means of men be sufficient, we should not have recourse to any useless 

contrivances, for it any useless contrivances, for it is absurd to 

employ mechanical means when not required; but if extension by men 

be not sufficient, you may use any of the mechanical powers which 

is suitable. When sufficiently extended, it will be easy to adjust 

the bones and bring them into their natural position, by straightening 

and arranging them with the palms of the hand. 



PART 16 

When the parts are adjusted, you should apply the bandages while the 
limb is in a stretched position, making the first turns to the right 
or to the left, as may be most suitable; and the end of the bandage 
should be placed over the fracture, and the first turns made at that 
place; and then the bandage should be carried up the leg, as described 
with regard to the other fractures . But the bandages should be broader 
and longer, and more numerous, in the case of the leg than in that 
of the arm. And when it is bandaged it should be laid upon some smooth 
and soft object, so that it may not be distorted to the one side or 
the other, and that there may be no protrusion of the bones either 
forward or backward; for this purpose nothing is more convenient than 
a cushion, or something similar, either of linen or wool, and not 
hard; it is to be made hollow along its middle, and placed below the 
limb. With regard to the canals (gutters?) usually placed below fractured 
legs, I am at a loss whether to advise that they should be used or 
not. For they certainly are beneficial, but not to the extent which 
those who use them suppose. For the canals do not preserve the leg 
at rest as they suppose; nor, when the rest of the body is turned 
to the one side or the other, does the canal prevent the leg from 
following, unless the patient himself pay attention; neither does 
the canal prevent the limb from being moved without the body to the 
one side or the other. And a board is an uncomfortable thing to have 
the limb laid upon, unless something soft be placed above it. But 
it is a very useful thing in making any subsequent arrangements of 
the bed and in going to stool. A limb then may be well or ill arranged 
with or without the canal. But the common people have more confidence, 
and the surgeon is more likely to escape blame, when the canal is 
placed under the limb, although it is not secundum artem. For the 
limb should by all means lie straight upon some level and soft object, 
since the bandaging must necessarily be overcome by any distortion 
in the placing of the leg, whenever or to whatever extent it may be 
inclined. The patient, when bandaged, should return the same answers 



as formerly stated, for the bandaging should be the same, and the 

same swellings should arise in the extremities, and the slackening 

of the bandages in like manner, and the new bandaging on the third 

day; and the bandaged part should be found reduced in swelling; and 

the new bandagings should be more tightly put on, and more pieces 

of cloth should be used; and the bandages should be carried loosely 

about the foot, unless the wound be near the knee. Extension should 

be made and the bones adjusted at every new bandaging; for, if properly 

treated, and if the swelling progress in a suitable manner, the bandaged 

limb will have become more slender and attenuated, and the bones will 

be more mobile, and yield more readily to extension. On the seventh, 

the ninth, or the eleventh day, the splints should be applied as described 

in treating of the other fractures. Attention should be paid to the 

position of the splints about the ankles and along the tendon of the 

foot which runs up the leg. The bones of the leg get consolidated 

in forty days, if properly treated. But if you suspect that anything 

is wanting to the proper arrangement of the limb, or dread any ulceration, 

you should loose the bandages in the interval, and having put everything 

right, apply them again. 



PART 17 

But if the other bone (fibula?) of the leg be broken, less powerful 
extension is required, and yet it must not be neglected, nor be performed 
slovenly, more especially at the first bandaging. For in all cases 
of fracture this object should be attained then as quickly as possible. 
For when the bandage is applied tight while the bones are not properly 
arranged, the properly arranged, the part becomes more painful. The 
treatment otherwise is the same. 



PART 18 

Of the bones of the leg, the inner one, called the tibia, is the more 
troublesome to manage, and requires the greater extension; and if 
the broken bones are not properly arranged, it is impossible to conceal 
the distortion, for the bone is exposed and wholly uncovered with 
flesh; and it is much longer before patients can walk on the leg when 
this bone is broken. But if the outer bone be broken, it causes much 
less trouble, and the deformity, when the bones are not properly set, 
is much more easily concealed, the bone being well covered with flesh; 
and the patients speedily get on foot, for it is the inner bone of 
the leg which supports the most of the weight of the body. For along 
with the thigh, as being in a line with weight thrown upon the thigh, 
the inner bone has more work to sustain; inasmuch as it is the head 
of the thigh-bone which sustains the upper part of the body, and it 
is on the inner and not on the outer side of the thigh, being in a 
line with the tibia; and the other half of the body approximates more 
to this line than to the external one; and at the same time the inner 
bone is larger than the outer, as in the fore-arm the bone in the 
line of the little finger is the slenderer and longer. But in the 
joint of the inferior extremity, the disposition of the longer bone 
is not alike, for the elbow and the ham are bent differently. For 
these reasons when the external bone is broken, the patients can soon 
walk about; but in fractures of the inner, it is a long time before 
they can walk. 



PART 19 



When the thigh-bone is broken, particular pains should be taken with 

regard to the extension that it may not be insufficient, for when 

excessive, no great harm results from it. For, if one should bandage 

a limb while the extremities of the bone are separated to a distance 

from one another by the force of the extension, the bandaging will 

not keep them separate, and so the bones will come together again 

as soon as the persons stretching it let go their hold; for the fleshy 

parts (muscles?) being thick and strong, are more powerful than the 

bandaging, instead of being less so. In the case then which we are 

now treating of, nothing should be omitted in order that the parts 

may be properly distended and put in a straight line; for it is a 

great disgrace and an injury to exhibit a shortened thigh. For the 

arm, when shortened, might be concealed, and the mistake would not 

be great; but a shortened thigh-bone would exhibit the man maimed. 

For when the sound limb is placed beside it, being longer than the 

other, it exposes the mistake, and therefore it would be to the advantage 

of a person who would be improperly treated that both his legs should 

be broken, rather than either of them; for in this case the one would 

be of the same length as the other. When, then, proper extension has 

been made, you must adjust the parts with the palms of the hands, 

and bandage the limb in the manner formerly described, placing the 

hands of the bandages as was directed, and making the turns upward. 

And the patient should return the same answers to the same questions 

as formerly, should be pained and recover in like manner, and should 

have the bandaging renewed in the same way; and the application of 

the splints should be the same. The thigh-bone is consolidated in 

forty days. 



PART 2 

But this also should be known, that the thigh-bone is curved rather 
to the outside than to the inside, and rather forward than backward; 
when not properly treated, then, the distortions are in these directions; 
and the bone is least covered with flesh at the same parts, so that 
the distortion cannot be concealed. If, therefore, you suspect anything 
of this kind, you should have recourse to the mechanical contrivances 
recommended in distortion of the arm. And a few turns of the bandage 
should be brought round by the hip and the loins, so that the groin 
and the articulation near the perineum may be included in the bandage; 
and moreover, it is expedient that the extremities of the splints 
should not do mischief by being placed on parts not covered with the 
bandages. The splints, in fact, should be carefully kept off the naked 
parts at both ends; and the arrangement of them should be so managed, 
as that they may not be placed on the natural protuberances of the 
bone at the knee-joint, nor on the tendon which is situated there. 



PART 21 

The swellings which arise in the ham, at the foot, or in any other 
part from the pressure, should be well wrapped in unsecured and carded 
wool, washed with wine and oil, and anointed with cerate, before bandaging; 
and if the splints give pain they should be slackened. You may sooner 
reduce the swellings, by laying aside the splints, and applying plenty 
of bandages to them, beginning from below and rolling upward; for 
thus the swellings will be most speedily reduced, and the humors be 
propelled to the parts above the former bandages. But this form of 
bandaging must not be used unless there be danger of vesications or 
blackening in the swelling, and nothing of the kind occurs unless 
the fracture be bound too tight, or unless the limb be allowed to 
hang, or it be rubbed with the hand, or some other thing of an irritant 



nature be applied to the skin. 



PART 2 2 

More injury than good results from placing below the thigh a canal 
which does not pass farther down than the ham, for it neither prevents 
the body nor the leg from being moved without the thigh. And it creates 
uneasiness by being brought down to the ham, and has a tendency to 
produce what of all things should be avoided, namely, flexion at the 
knee, for this completely disturbs the bandages; and when the thigh 
and leg are bandaged, if one bend the limb at the knee, the muscles 
necessarily assume another shape, and the broken bones are also necessarily 
moved. Every endeavor then should be made to keep the ham extended. 
But it appears to me, that a canal which embraces the limb from the 
nates to the foot is of use. And moreover, a shawl should be put loosely 
round at the ham, along with the canal, as children are swathed in 
bed; and then, if the thigh-bone gets displaced either upward or to 
the side, it can be more easily kept in position by this means along 
with the canal. The canal then should be made so as to extend all 
along the limb or not used at all. 



PART 2 3 

The extremity of the heel should be particularly attended to, so that 
it may be properly laid, both in fractures of the leg and of the thigh. 
For if the foot be placed in a dependent position, while the rest 
of the body is supported, the limb must present a curved appearance 
at the forepart of the leg; and if the heel be placed higher than 
is proper, and if the rest of the leg be rather too low, the bone 
at the forepart of the leg must present a hollow, more especially 
if the heel of the patient be naturally large. But all the bones get 
consolidated more slowly, if not laid properly, and if not kept steady 
in the same position, and in this case the callus is more feeble. 



PART 2 4 

These things relate to cases in which there is fracture of the bones 
without protrusion of the same or wound of any other kind. In those 
cases in which the bones are simply broken across, and are not comminuted, 
but protrude, if reduced the same day or next, and secured in their 
place, and if there be no reason to anticipate that any splintered 
bones will come away; and in those in which the broken bones do not 
protrude, nor is the mode of fracture such that there is reason to 
expect the splinters will come out, some physicians heal the sores 
in a way which neither does much good nor harm, by means of a cleansing 
application, applying pitch ointment, or some of the dressings for 
fresh wounds, or anything else which they are accustomed to do, and 
binding above them compresses wetted with wine, or greasy wool, or 
something else of the like nature. And when the wounds become clean 
and are new healed, they endeavor to bind up the limb with plenty 
of bandages, and keep it straight with treatment does some good, and 
never much harm. The bones, however, can never be equally well restored 
to their place, but the part is a little more swelled than it should 
be; and the limb will be somewhat shortened, provided both bones either 
of the leg or fore-arm have been fractured. 



PART 2 5 

There are others who treat such cases at first with bandages, applying 

them on both sides of the seat of the injury, but omit them there, 

and leave the wound uncovered, and afterward they apply to the wound 

some cleansing medicine, and complete the dressing with compresses 

dipped in wine and greasy wool. This plan of treatment is bad, and 

it is clear that those who adopt this mode of practice are guilty 

of great mistakes in other cases of fracture as well as these. For 

it is a most important consideration to know in what manner the head 

of the bandage should be placed and at what part the greatest pressure 

should be, and what benefits would result from applying the end of 

the bandage and the pressure at the proper place, and what mischiefs 

would result from applying the head of the bandage and the pressure 

otherwise than at the proper place. Wherefore it has been stated in 

the preceding part of the work what are the results of either; and 

the practice of medicine bears witness to the truth of it, for in 

a person thus bandaged, a swelling must necessarily arise on the wound. 

For, if even a sound piece of skin were bandaged on either side, and 

a part were left in the middle, the part thus left unbandaged would 

become most swelled, and would assume a bad color; how then could 

it be that a wound would not suffer in like manner? The wound then 

must necessarily become discolored and its lips everted, the discharge 

will be ichorous and without pus, and the bones, which should not 

have got into a state of necrosis, exfoliate; and the wound gets into 

a throbbing and inflamed condition. And they are obliged to apply 

a cataplasm on account of the swelling, but this is an unsuitable 

application to parts which are bandaged on both sides, for a useless 

load is added to the throbbing which formerly existed in it. At last 

they loose the bandages when matters get very serious, and conduct 

the rest of the treatment without bandaging; and notwithstanding, 

if they meet with another case of the same description, they treat 

it in the same manner, for they do not think that the application 

of the bandages on both sides, and the exposure of the wound are the 

cause of what happened, but some other untoward circumstance. Wherefore 

I would not have written so much on this subject, if I had not well 

known that this mode of bandaging is unsuitable, and yet that many 

conduct the treatment in this way, whose mistake it is of vital importance 

to correct, while what is here said is a proof, that what was formerly 

written as to the circumstances under which bandages should be tightly 

applied to fractures or otherwise has been correctly written. 



PART 2 6 

As a general rule it may be said, that in those cases in which a separation 

of bone is not expected, the same treatment should be applied as when 

the fractures are not complicated with an external wound; for the 

extension, adjustment of the bones, and the bandaging, are to be conducted 

in the same manner. To the wound itself a cerate mixed with pitch 

is to be applied, a thin folded compress is to be bound upon it, and 

the parts around are to be anointed with white cerate. The cloths 

for bandages and the other things should be torn broader than in cases 

in which there is no wound, and the first turn of the bandage should 

be a good deal broader than the wound. For a narrower bandage than 

the wound binds the wound like a girdle, which is not proper, or the 

first turn should comprehend the whole wound, and the bandaging should 

extend beyond it on both sides. The bandage then should be put on 

in the direction of the wound, and should be not quite so tight as 

when there is no wound, but the bandage should be otherwise applied 

in the manner described above. The bandages should be of a soft consistence, 

and more especially so in such cases than in those not complicated 

with a wound. The number of bandages should not be smaller, but rather 



greater than those formerly described. When applied, the patient should 

have the feeling of the parts being properly secured, but not too 

tight, and in particular he should be able to say that they are firm 

about the wound. And the intervals of time during which the parts 

seem to be properly adjusted, and those in which they get loose, should 

be the same as those formerly described. The bandages should be renewed 

on the third day, and the after treatment conducted in the same manner 

as formerly described, except that in the latter case the compression 

should be somewhat less than in the former. And if matters go on properly, 

the parts about the wound should be found at every dressing always 

more and more free of swelling, and the swelling should have subsided 

on the whole part comprehended by the bandages . And the suppurations 

will take place more speedily than in the case of wounds treated otherwise; 

and the pieces of flesh in the wound which have become black and dead, 

will sooner separate and fall off under this plan of treatment than 

any other, and the sore will come more quickly to cicatrization when 

thus treated than otherwise. The reason of all this is, that the parts 

in which the wound is situated, and the surrounding parts, are kept 

free of swelling. In all other respects the treatment is to be conducted 

as in cases of fracture without a wound of the integuments. Splints 

should not be applied. On this account the bandages should be more 

numerous than in the former case, both because they must be put on 

less tight, and because the splints are later of being applied. But 

if you do apply the splints, they should not be applied along the 

wound, and they are to be put on in a loose manner, especial care 

being taken that there may be no great compression from the splints. 

This direction has been formerly given. And the diet should be more 

restricted, and for a longer period, in those cases in which there 

is a wound at the commencement, and when the bones protrude through 

the skin; and, in a word, the greater the wound, the more severe and 

protracted should the regimen be. 



PART 2 7 

The treatment of the sores is the same in those cases of fracture 

in which there was no wound of the skin at first, but one has formed 

in the course of treatment, owing to the pressure of the splints occasioned 

by the bandages, or from any other cause. In such cases it is ascertained 

that there is an ulcer, by the pain and the throbbing; and the swelling 

in the extremities becomes harder than usual, and if you apply your 

finger the redness disappears, but speedily returns. If you suspect 

anything of the kind you must loose the dressing, if there be any 

itching below the under-bandages, or in any other part that is bandaged, 

and used a pitched cerate instead of the other. If there be nothing 

of that, but if the ulcer be found in an irritable state, being very 

black and foul, and the fleshy parts about to suppurate, and the tendons 

to slough away, in these cases no part is to be exposed to the air, 

nor is anything to be apprehended from these suppurations, but the 

treatment is to be conducted in the same manner as in those cases 

in which there was an external wound at first. You must begin to apply 

the bandages loosely at the swelling in the extremities, and then 

gradually proceed upward with the bandaging, so that it may be tight 

at no place, but particularly firm at the sore, and less so elsewhere. 

The first bandages should be clean and not narrow, and the number 

of bandages should be as great as in those cases in which the splints 

were used, or somewhat fewer. To the sore itself a compress, anointed 

with white cerate, will be sufficient, for if a piece of flesh or 

nerve (tendon?) become black, it will fall off; for such sores are 

not to be treated with acrid, but with emollient applications, like 

burns. The bandages are to be renewed every third day, and no splints 

are to be applied, but rest is to be more rigidly maintained than 

in the former cases, along with a restricted diet. It should be known. 



that if any piece of flesh or tendon be to come away, the mischief 
will spread much less, and the parts will much more speedily drop 
off, and the swelling in the surrounding parts will much more completely 
subside, under this treatment, than if any of the cleansing applications 
be put upon the sore. And if any part that is to come away shall fall 
off, the part will incarnate sooner when thus treated than otherwise, 
and will more speedily cicatrize. Such are the good effects of knowing 
how a bandage can be well and moderately applied. But a proper position, 
the other parts of the regimen, and suitable bandages cooperate. 



PART 2 8 

If you are deceived with regard to a recent wound, supposing there 
will be no exfoliation of the bones, while they are on the eve of 
coming out of the sore, you must not hesitate to adopt this mode of 
treatment; for no great mischief will result, provided you have the 
necessary dexterity to apply the bandages well and without doing any 
harm. And this is a symptom of an exfoliation of bone being about 
to take place under this mode of treatment; pus runs copiously from 
the sore, and appears striving to make its escape. The bandage must 
be renewed more frequently on account of the discharge, since otherwise 
fevers come on; if the sore and surrounding parts be compressed by 
the bandages they become wasted. Cases complicated with the exfoliation 
of very small bones, do not require any change of treatment, only 
the bandages should be put on more loosely, so that the discharge 
of pus may not be intercepted, but left free, and the dressings are 
to be frequently renewed until the bone exfoliate, and the splints 
should not be applied until then. 



PART 2 9 

Those cases in which the exfoliation of a larger piece of bone is 
expected, whether you discover this at the commencement, or perceive 
subsequently that it is to happen, no longer require the same mode 
of treatment, only that the extension and arrangement of the parts 
are to be performed in a manner that has been described; but having 
formed double compresses, not less than half a fathom in breadth (being 
guided in this by the nature of the wound) , and considerably shorter 
than what would be required to go twice round the part that is wounded, 
but considerably longer than to go once round, and in number what 
will be sufficient, these are to be dipped in a black austere wine; 
and beginning at the middle, as is done in applying the double-headed 
bandage, you are to wrap the part around and proceed crossing the 
heads in the form of the bandage called "ascia." These things are 
to be done at the wound, and on both sides of it; and there must be 
no compression, but they are to be laid on so as to give support to 
the wound. And on the wound itself is to be applied the pitched cerate, 
or one of the applications to recent wounds, or any other medicine 
which will suit with the embrocation. And if it be the summer season, 
the compresses are to be frequently damped with wine; but if the winter 
season, plenty of greasy wool, moistened with wine and oil, should 
be applied. And a goat's skin should be spread below, so as to carry 
off the fluids which run from the wound; these must be guarded against, 
and it should be kept in mind, that parts which remain long in the 
same position are subject to excoriations which are difficult to cure. 



PART 30 



In such cases as do not admit of bandaging according to any of the 

methods which have been described, or which will be described, great 

pains should be taken that the fractured part of the body be laid 

in a right position, and attention should be paid that it may incline 

upward rather than downward. But if one would wish to do the thing 

well and dexterously, it is proper to have recourse to some mechanical 

contrivance, in order that the fractured part of the body may undergo 

proper and not violent extension; and this means is particularly applicable 

in fractures of the leg. There are certain physicians who, in all 

fractures of the leg, whether bandages be applied or not, fasten the 

sole of the foot to the couch, or to some other piece of wood which 

they have fixed in the ground near the couch. These persons thus do 

all sorts of mischief but no good; for it contributes nothing to the 

extension that the foot is thus bound, as the rest of the body will 

no less sink down to the foot, and thus the limb will no longer be 

stretched, neither will it do any good toward keeping the limb in 

a proper position, but will do harm, for when the rest of the body 

is turned to this side or that, the bandaging will not prevent the 

foot and the bones belonging to it from following the rest of the 

body. For if it had not been bound it would have been less distorted, 

as it would have been the less prevented from following the motion 

of the rest of the body. But one should sew two balls of Egyptian 

leather, such as are worn by persons confined for a length of time 

in large shackles, and the balls the balls should have coats on each 

side, deeper toward the wound, but shorter toward the joints; and 

the balls should be well stuffed and soft, and fit well, the one above 

the ankles, and the other below the knee. Sideways it should have 

below two appendages, either of a single or double thong, and short, 

like loops, the one set being placed on either side of the ankle, 

and the other on the knee. And the other upper ball should have others 

of the same kind in the same line. Then taking four rods, made of 

the cornel tree, of equal length, and of the thickness of a finger, 

and of such length that when bent they will admit of being adjusted 

to the appendages, care should be taken that the extremities of the 

rods bear not upon the skin, but on the extremities of the balls. 

There should be three sets of rods, or more, one set a little longer 

than another, and another a little shorter and smaller, so that they 

may produce greater or less distention, if required. Either of these 

sets of rods should be placed on this side and that of the ankles. 

If these things be properly contrived, they should occasion a proper 

and equable extension in a straight line, without giving any pain 

to the wound; for the pressure, if there is any, should be thrown 

at the foot and the thigh. And the rods are commodiously arranged 

on either side of the ankles, so as not to interfere with the position 

of the limb; and the wound is easily examined and easily arranged. 

And, if thought proper, there is nothing to prevent the two upper 

rods from being fastened to one another; and if any light covering 

be thrown over the limb, it will thus be kept off from the wound. 

If, then, the balls be well made, handsome, soft, and newly stitched, 

and if the extension by the rods be properly managed, as has been 

already described, this is an excellent contrivance; but if any of 

them do not fit properly, it does more harm than good. And all other 

mechanical contrivances should either be properly done, or not be 

had recourse to at all, for it is a disgraceful and awkward thing 

to use mechanical means in an unmechanical way. 



PART 31 

Moreover, the greater part of physicians treat fractures, both with 
and without an external wound, during the first days, by means of 
unwashed wool, and there does not appear to be anything improper in 
this. It is very excusable for those who are called upon to treat 



newly-received accidents of this kind, and who have no cloth for bandages 

at hand, to do them up with wool; for, except cloth for bandages, 

one could not have anything better than wool in such cases; but a 

good deal should be used for this purpose, and it should be well carded 

and not rough, for in small quantity and of a bad quality it has little 

power. But those who approve of binding up the limb with wool for 

a day or two, and on the third and fourth apply bandages, and make 

the greatest compression and extension at that period, such persons 

show themselves to be ignorant of the most important principles of 

medicine; for, in a word, at no time is it so little proper to disturb 

all kinds of wounds as on the third and fourth day; and all sort of 

probing should be avoided on these days in whatever other injuries 

are attended with irritation. For, generally, the third and fourth 

day in most cases of wounds, are those which give rise to exacerbations, 

whether the tendency be to inflammation, to a foul condition of the 

sore, or to fevers. And if any piece of information be particularly 

valuable this is; to which of the most important cases in medicine 

does it not apply? and that not only in wounds but in many other diseases, 

unless one should call all other diseases wounds. And this doctrine 

is not devoid of a certain degree of plausibility, for they are allied 

to one another in many respects . But those who maintain that wool 

should be used until after the first seven days, and then that the 

parts should be extended and adjusted, and secured with bandages, 

would appear not to be equally devoid of proper judgment, for the 

proper judgment, for the most dangerous season for inflammation is 

then past, and the bones being loose can be easily set after the lapse 

of these days. But still this mode of treatment is far inferior to 

that with bandages from the commencement; for, the latter method exhibits 

the patient on the seventh day free from inflammation, and ready for 

complete bandaging with splints; while the former method is far behind 

in this respect, and is attended with many other bad effects which 

it would be tedious to describe. 

31a. In those cases of fracture in which the bones protrude and cannot 
be restored to their place, the following mode of reduction may be 
practiced:- Some small pieces of iron are to be prepared like the 
levers which the cutters of stone make use of, one being rather broader 
and another narrower; and there should be three of them at least, 
and still more, so that you may use those that suit best; and then, 
along with extension, we must use these as levers, applying the under 
surface of the piece of iron to the under fragment of the bone, and 
the upper surface to the upper bone; and, in a word, we must operate 
powerfully with the lever as we would do upon a stone or a piece of 
wood. The pieces of iron should be as strong as possible, so that 
they may not bend. This is a powerful assistance, provided the pieces 
of iron be suitable, and one use them properly as levers. Of all the 
mechanical instruments used by men, the most powerful are these three, 
the axis in peritrochio, the lever, and the wedge. Without these, 
one or all, men could not perform any of their works which require 
great force. Wherefore, reduction with the lever is not to be despised, 
for the bones will be reduced in this way, or not at all. But if the 
upper fragment which rides over the other does not furnish a suitable 
point of support a suitable point of support for the lever, but the 
protruding part is sharp, you must scoop out of the bone what will 
furnish a proper place for the lever to rest on. The lever, along 
with extension, may be had recourse to on the day of the accident, 
or the accident, or next day, but by no means on the third, the fourth, 
and the fifth. For if the limb is disturbed on these days, and yet 
the fractured bones not reduced, inflammation will be excited, and 
this no less if they are reduced; for convulsions are more apt to 
occur if reduction take place, than if the attempt should fail. These 
facts should be well known, for if convulsions should come on when 
reduction is effected, there effected, there is little hope of recovery; 
but it is of use to displace the bones again if this can be done with 



out trouble. For it is not at the time when the parts are in a particularly 

relaxed condition that convulsions and tetanus are apt to supervene, 

but when they are more than usually tense. In the case we are now 

treating of, we should not disturb the limb on the aforesaid days, 

but strive to keep the wound as free from inflammation as possible, 

and especially encourage suppuration in it. But when seven days have 

elapsed, or rather more, if there be no fever, and if the wound be 

not inflamed, then there will be less to prevent an attempt at reduction, 

if you hope to succeed; but otherwise you need not take and give trouble 

in vain. 



PART 32 

When you have reduced the bones to their place, the modes of treatment, 
whether you expect the bones to exfoliate or not, have been already 
described. All those cases in which an exfoliation of bone is expected, 
should be treated by the method of bandaging with cloths, beginning 
for the most part at the middle of the bandage, as is done with the 
double-headed bandage; but particular attention should be paid to 
the shape of the wound, so that its lips may gape or be distorted 
as little as possible under the bandage. Sometimes the turns of the 
bandage have to be made to the right, and sometimes to the left, and 
sometimes a double-headed bandage is to be used. 



PART 33 

It should be known that bones, which it has been found impossible 

to reduce, as well as those which are wholly denuded of flesh, will 

become detached. In some cases the upper part of the bone is laid 

bare, and in others the flesh dies all around; and, from a sore of 

long standing, certain of the bones become carious, and some not, 

some more, and some less; and in some the small, and in others the 

large bones. From what has been said it will be seen, that it is impossible 

to tell in one word when the bones will separate. Some come away more 

quickly, owing to their smallness, and some from being merely fixed 

at the point; and some, from pieces not separating, but merely exfoliating, 

become dried up and putrid; and besides, different modes of treatment 

have different effects. For the most part, the bones separate most 

quickly in those cases in which suppuration takes place most quickly, 

and when new flesh is most quickly formed, and is particularly sound, 

for the flesh which grows up below in the wound generally elevates 

the pieces of bone. It will be well if the whole circle of the bone 

separate in forty days; for in some cases it is protracted to sixty 

days, and in some to more; for the more porous pieces of bone separate 

more quickly, but the more solid come away more slowly; but the other 

smaller splinters in much less time, and others otherwise. A portion 

of bone which protrudes should be sawn off for the following reasons: 

if it cannot be reduced, and if it appears sons: that only a small 

piece is required in order that it may get back into its place; and 

if it be such that it can be taken out, and if it occasions inconvenience 

and irritates any part of the flesh, and prevents the limb from being 

properly laid, and if, moreover, it be denuded of flesh, such a piece 

of bone should be taken off. With regard to the others, it is not 

of much consequence whether they be sawed off or not. For it should 

be known for certain, that such bones as are completely deprived of 

flesh, and have become dried, all separate completely. Those which 

are about to exfoliate should not be sawn off. Those that will separate 

completely must be judged of from the symptoms that have been laid 

down . 



PART 34 

Such cases are to be treated with compresses and vinous applications, 
as formerly laid down regarding bones which will separate. We must 
avoid wetting it at the beginning with anything cold; for there is 
danger of febrile rigors, and also of convulsions; for convulsions 
are induced by cold things, and also sometimes by wounds. It is proper 
to know that the members are necessarily shortened in those cases 
in which the bones have been broken, and have healed the one across 
the other, and in those cases in which the whole circle of the bone 
has become detached. 



PART 35 

Those cases in which the bone of the thigh, or of the arm, protrudes, 

do not easily recover. For the bones are large, and contain much marrow; 

and many important nerves, muscles, and veins are wounded at the same 

time. And if you reduce them, convulsions usually supervene; and, 

if not reduced, acute bilious fevers come on, with singultus and mortification. 

The chances of recovery are not fewer in those cases in which the 

parts have not been reduced, nor any attempts made at reduction. Still 

more recover in those cases in which the lower, than those in which 

the upper part of the bone protrudes; and some will recover when reduction 

has been made, but very rarely indeed. For modes of treatment and 

peculiarity of constitution make a great difference as to the capability 

of enduring such an injury. And it makes a great difference if the 

bones of the arm and of the thigh protrude to the inside; for there 

are many and important vessels situated there, some of which, if wounded, 

will prove fatal; there are such also on the outside, but of less 

importance. In wounds of this sort, then, one ought not to be ignorant 

of the dangers, and should prognosticate them in due time. But if 

you are compelled to have recourse to reduction, and hope to succeed, 

and if the bones do not cross one another much, and if the muscles 

are not contracted (for they usually are contracted), the lever in 

such cases may be advantageously employed. 



PART 3 6 

Having effected the reduction, you must give an emollient draught 
of hellebore the same day, provided it has been reduced on the day 
of the accident, but otherwise it should not be attempted. The wound 
should be treated with the same things as are used in fractures of 
the bones of the head, and nothing cold should be applied; the patient 
should be restricted from food altogether, and if naturally of a bilious 
constitution, he should have for a diet a little fragrant oxyglyky 
sprinkled on water; but if he is not bilious, he should have water 
for drink; and if fever of the continual type come on, he is to be 
confined to this regimen for fourteen days at least, but if he be 
free of fever, for only seven days, and then you must bring him back 
by degrees to a common diet. To those cases in which the bones have 
not been reduced, a similar course of medicine should be administered, 
along with the same treatment of the sores and regimen; and in like 
manner the suspended part of the body should not be stretched, but 
should rather be contracted, so as to relax the parts about the wound. 
The separation of the bones is protracted, as also was formerly stated. 
But one should try to escape from such cases, provided one can do 
so honourably, for the hopes of recovery are small, and the dangers 
many; and if the physician do not reduce the fractured bones he will 



be looked upon as upon as unskillful, while by reducing them he will 
bring the patient nearer to death than to recovery. 



PART 37 

Luxations and subluxations at the knee are much milder accidents than 

subluxations and luxations at the elbow. For the knee-joint, in proportion 

to its size, is more compact than that of the arm, and has a more 

even conformation, and is rounded, while the joint of the arm is large, 

and has many cavities. And in addition, the bones of the leg are nearly 

of the same length, for the external one overtops the other to so 

small an extent as hardly to deserve being mentioned, and therefore 

affords no great resistance, although the external nerve (ligament?) 

at the ham arises from it; but the bones of the fore-arm are unequal, 

and the shorter is considerably thicker than the other, and the more 

slender (ulna?) protrudes, and passes up above the joint, and to it 

(the olecranon?) are attached the nerves (ligaments?) which go downward 

to the junction of the bones; and the slender bone (ulna?) has more 

to do with the insertion of the ligaments in the arm than the thick 

bone (radius?) . The configuration then of the articulations, and of 

the bones of the elbow, is such as I have described. Owing to their 

configuration, the bones at the knee are indeed frequently dislocated, 

but they are easily reduced, for no great inflammation follows, nor 

any constriction of the joint. They are displaced for the most part 

to the inside, sometimes to the outside, and occasionally into the 

ham. The reduction in all these cases is not difficult, but in the 

dislocations inward and outward, the patient should be placed on a 

low seat, and the thigh should be elevated, but not much. Moderate 

extension for the most part sufficeth, extension being made at the 

leg, and counter-extension at the thigh. 



PART 38 

Dislocations at the elbow are more troublesome than those at the knee, 

and, owing to the inflammation which comes on, and the configuration 

of the joint, are more difficult to reduce if the bones are not immediately 

replaced. For the bones at the elbow are less subject to dislocation 

than those of the knee, but are more difficult to reduce and keep 

in their position, and are more apt to become inflamed and ankylosed. 



PART 3 9 

For the most part the displacements of these bones are small, sometimes 
toward the ribs, and sometimes to the outside; and the whole articulation 
is not displaced, but that part of the humerus remains in place which 
is articulated with the cavity of the bone of the forearm that has 
a protuberance (ulna?) . Such dislocations, to whatever side, are easily 
reduced, and the extension is to be made in the line of the arm, one 
person making extension at the wrist, and another grasping the armpit, 
while a third, applying the palm of his hand to the part of the joint 
which is displaced, pushes it inward ward, and at the same time makes 
counterpressure on the opposite side near the joint with the other 
hand . 



PART 4 



The end of the humerus at the , elbow gets displaced (subluxated?) 

by leaving the cavity of the ulna. Such luxations readily yield to 

reduction, if applied before the parts get inflamed. The displacement 

for the most part is to the inside, but sometimes to the outside, 

and they are readily recognized by the shape of the limb. And often 

such luxations are reduced without any powerful extension. In dislocations 

inward, the joint is to be pushed into its place, while the fore-arm 

is brought round to a state of pronation. Such are most of the dislocations 

at the elbow. 



PART 41 

But if the articular extremity of the humerus be carried to either 

side above the bone of the fore-arm, which is prominent, into the 

hollow of the arm (?), this rarely happens; but if it does happen, 

extension in the straight line is not so proper under such circumstances; 

for in such a mode of extension, the process of the ulna (olecranon?) 

prevents the bone of the arm (humerus?) from passing over it. In dislocations 

of this kind, extension should be made in the manner described when 

treating of the bandaging of fractured bones of the arm, extension 

being made upward at the armpit, while the parts at the elbow are 

pushed downward, for in this manner can the humerus be most readily 

raised above its cavity; and when so raised, the reduction is easy 

with the palms of the hand, the one being applied so as to make pressure 

on the protuberant part of the arm, and the other making counter-pressure, 

so as to push the bone of the fore-arm into the joint. This method 

answers with both cases. And perhaps this is the most suitable mode 

of reduction in such a case of dislocation. The parts may be reduced 

by extension in a straight line, but less readily than thus. 



PART 4 2 

If the arm be dislocated forward- this rarely happens, indeed, but 

what would a sudden shock not displace? for many other things are 

removed from their proper place, notwithstanding a great obstacle, - 

in such a violent displacement the part (olecranon?) which passes 

above the prominent part of the bones is large, and the stretching 

of the nerves (ligaments?) is intense; and yet the parts have been 

so dislocated in certain cases. The following is the symptom of such 

a displacement: the arm cannot be bent in the least degree at the 

elbow, and upon feeling the joint the nature of the accident becomes 

obvious. If, then, it is not speedily reduced, strong and violent 

inflammation, attended with fever, will come on, but if one happen 

to be on the spot at the time it is easily reduced. A piece of hard 

linen cloth (or a piece of hard linen, not very large, rolled up in 

a ball, will be sufficient) is to be placed across the bend of the 

elbow, and the arm is then to be suddenly bent at the elbow, and the 

hand brought up to the shoulder. This mode of reduction is sufficient 

in such displacements; and extension in the straight line can rectify 

this manner of dislocation, but we must use at the same time the palms 

of the hands, applying the one to the projecting part of the humerus 

at the bend of the arm for the purpose of pushing it back, and applying 

the other below to the sharp extremity of the elbow, to make counter-pressure, 

and incline the parts into the straight line. And one may use with 

advantage in this form of dislocation the method of extension formerly 

described, for the application of the bandages in the case of fracture 

of the arm; but when extension is made, the parts are to be adjusted, 

as has been also described above. 



PART 4 3 

But if the arm be dislocated backward (but this very rarely happens, 
and it is the most painful of all, and the most subject to bilious 
fevers of the continual type, which prove fatal in the course of a 
few days), in such a case the patient cannot extend the arm. If you 
are quickly present, by forcible extension the parts may return to 
their place of their own accord; but if fever have previously come 
on, you must no longer attempt reduction, for the pain will be rendered 
more intense by any such violent attempt. In a word, no joint whatever 
should be reduced during the prevalence of fever, and least of all 
the elbow-joint. 



PART 4 4 

There are also other troublesome injuries connected with the elbow-joint; 
for example, the thicker bone (radius?) is sometime partially displaced 
from the other, and the patient can neither perform extension nor 
flexion properly. This accident becomes obvious upon examination with 
the hand at the bend of the arm near the division of the vein that 
runs up the muscle. In such a case it is not easy to reduce the parts 
to their natural state, nor is it easy, in the separation of any two 
bones united by symphysis, to restore them to their natural state, 
for there will necessarily be a swelling at the seat of the diastasis. 
The method of bandaging a joint has been already described in treating 
of the application of bandages to the ankle. 



PART 4 5 

In certain cases the process of the ulna (olecranon?) behind the humerus 
is broken; sometimes its cartilaginous part, which gives origin to 
the posterior tendon of the arm, and sometimes its fore part, at the 
base of the anterior coronoid process; and when this displacement 
takes place, it is apt to be attended with malignant fever. The joint, 
however, remains in place, for its whole base protrudes at that point. 
But when the displacement takes place where its head overtops the 
arm, the joint becomes looser if the bone be fairly broken across. 
To speak in general terms, all cases of fractured bones are less dangerous 
than those in which the bones are not broken, but the veins and important 
nerves (tendons?) situated in these places are contused; for the risk 
of death is more immediate in the latter class of cases than in the 
former, if continual fever come on. But fractures of this nature seldom 
occur . 



PART 4 6 

It sometimes happens that the head of the humerus is fractured at 
its epiphysis; and this, although it may appear to be a much more 
troublesome accident, is in fact a much milder one than the other 
injuries at the joint. 



PART 4 7 

The treatment especially befitting each particular dislocation has 
been described; and it has been laid down as a rule, that immediate 



reduction is of the utmost advantage, owing to the rapid manner in 

which inflammation of the tendons supervenes. For even when the luxated 

parts are immediately reduced, the tendons usually become stiffened, 

and for a considerable time prevent extension and flexion from being 

performed to the ordinary extent, are to be treated in a similar way, 

whether the extremity of the articulating bone be snapped off, whether 

the bones be separated, or whether they be dislocated; for they are 

all to be treated with plenty of bandages, compresses, and cerate, 

like other fractures. The position of the joint in all these cases 

should be the same, as when a fractured arm or fore-arm has been bound 

up. For this is the most common position in all dislocations, displacements, 

and fractures; and it is the most convenient for the subsequent movements, 

whether of extension or flexion, as being the intermediate stage between 

both. And this is the position in which the patient can most conveniently 

carry or suspend his arm in a sling. And besides, if the joint is 

to be stiffened by callus, it were better that this should not take 

place when the arm is extended, for this position will be a great 

impediment and little advantage; if the arm be wholly bent, it will 

be more useful; but it will be much more convenient to have the joint 

in the intermediate position when it becomes ankylosed. So much with 

regard to position. 



PART 4 8 

In bandaging, the head of the first bandage should be placed at the 
seat of the injury, whether it be a case of fracture, of dislocation, 
or of diastasis (separation?), and the first turns should be made 
there, and the bandages should be applied most firmly at that place, 
and less so on either side. The bandaging should comprehend both the 
arm and the fore-arm, and on both should be to a much greater extent 
than most physicians apply it, so that the swelling may be expelled 
from the seat of the injury to either side. And point of the fore-arm 
should be comprehended in the bandaging, whether the injury be in 
that place or not, in order that the swelling may not collect there. 
In applying bandages, we must avoid as much as possible accumulating 
many turns of the bandage at the bend of the arm. For the principal 
compression should be at the seat of the injury, and the same rules 
are to be observed, and at the same periods, with regard to compression 
and relaxation, as formerly described respecting the treatment of 
broken bones; and the bandages should be renewed every third day; 
and they should appear loose on the third day, as in the other case. 
And splints should be applied at the proper time (for there is nothing 
unsuitable in them, whether the bones be fractured or not, provided 
there is no fever) ; they should be particularly loose, whether applied 
to the arm or the forearm, but they must not be thick. It is necessary 
that they should be of unequal size, and that the one should ride 
over the other, whenever from the flexion it is judged proper. And 
the application of the compresses should be regulated in the same 
manner as has been stated with regard to the splints; and they should 
be put on in a somewhat more bulky form at the seat of the injury. 
The periods are to be estimated from the inflammation, and from what 
has been written on them above. 

THE END